Urological Emergencies in Clinical Practice стр.132

172 J. REYNARD AND N. COWAN

a

Urological Emergencies in Clinical Practice

FIGURE 10.1. a: A flexible cystoscope has been passed into the bladder and a guidewire is manipulated into the ureter under direct vision. (See this figure in full color in the insert.) b: Under fluoroscopic control, the guidewire is advanced up the ureter and into the renal pelvis. c: The lower end of the stent is seen deployed in the bladder. (See this figure in full color in the insert.) d: Previously instilled contrast medium can be used to confirm that the stent is in the correct position.

Urological Emergencies in Clinical Practice

FIGURE 10.1. Continued

174 J. REYNARD AND N. COWAN

Urological Emergencies in Clinical Practice

FIGURE 10.1. Continued

Urological Emergencies in Clinical Practice

FIGURE 10.1. Continued

176 J. REYNARD AND N. COWAN

PERCUTANEOUS NEPHROSTOMY INSERTION

Indications in Urological Emergencies

Preparation of the Patient for Nephrostomy Insertion

Patients should have their blood clotting checked and serum should be grouped and saved in case heavy bleeding occurs and blood transfusion is required. Verbal consent should be taken and the discussion about risks documented in the patient's notes (see Complications, below).

Technique

This procedure is performed under local anaesthetic with or without sedation, and with antibiotic cover (depending on urine culture; cefuroxime and gentamicin if no culture result is available). The patient lies prone. A nephrostomy needle is inserted into the renal pelvis and contrast is instilled to outline the collecting system of the kidney (Fig. 10.2a). A guidewire is passed into the renal pelvis (Fig. 10.2b), and over this the nephrostomy tube is advanced (Fig. 10.2c).

Complications

These will depend on how experienced the radiologist is and on how many nephrostomies he or she inserts per year. The complication rate of dedicated uroradiologists is lower than that which is generally regarded as acceptable (Ramchandani et al. 2001). Quoted complication rates should be those relevant to your hospital.

In the U.K., acceptable complication rates are haemorrhage requiring embolisation or surgery 1%, septic shock 4%, damage to adjacent organs <1%, and failure to drain the kidney approximately 5% (Ramchandani et al. 2001), but some series report complication rates that are below these (Ho and Cowan 2001).


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